Date : 00.00.00
Name of the Patient : Abc XyzMlmn / F / 50 yrs.
Referred by : Dr. Abc Xyzni.
Examination : M.R.I. of the Lumbo-sacral Spine.
CLINICAL PROFILE :
C/O backache radiating to the RLE since 7-8 years.
H/O spine surgery (twice) 7 years back (details unavailable).
M.R.I of the lumbo-sacral spine was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images.
The L3-L4, L4-L5 and L5-S1 intervertebral discs show loss of water content.
There appears to be partial laminectomy of the L4 and L5 vertebral bodies with changes in the posterior soft tissues of the back.
There is slight forward translation of the L4 over the L5 vertebral body. A pseudo-posterior disc herniation is seen at the L4-L5 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L4-L5 facet joints show hypertrophic degenerative changes with lateral canal stenosis.
A posterior disc herniation is seen at the L5-S1 level with anterior indentation of the thecal sac and bilateral neural foraminal narrowing. The L5-S1 facet joint on the right side shows gross hypertrophic degenerative change. Ligamentum flavum hypertrophy is also noted at this level with resultant canal stenosis.
A small posterior disc bulge is noted at the L3-L4 level.
There is anterior wedging of the D11 vertebral body. Hemangiomas with fatty content are noted in the D11, L1 and the L2 vertebral bodies.
The rest of the lumbar vertebral bodies and the remaining intervertebral discs reveal normal signal intensity. The rest of the facet joints and the visualized pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the L1-L2 level and the thecal sac terminates at the S2 level.
The antero-posterior dimensions of the lumbar canal at the level of the intervertebral discs are as follows :
12.0 mm at L1-L2
12.0 mm at L2-L3
11.0 mm at L3-L4
10.0 mm at L4-L5
9.0 mm at L5-S1.
The MRI features are suggestive of :
1. Post-operative status.
- 3 - Scan-00000
2. A pseudo-posterior disc herniation at the L4-L5 level with hypertrophic facetal arthropathy and resultant canal stenosis.
3. A posterior disc herniation at the L5-S1 level with
ligamentum flavum hypertrophy bilaterally and gross hypertrophic facetal arthropathy on the right side with resultant canal stenosis.